MAUDE Adverse Event Report: ETHICON INC. ETHLN BLK 96IN 0 S/A CT LP; SUTURE, NONABSORBABLE, SYNTHETIC

Catalog Number	L886T
Medical Device Problem Code	Break (1069)
Health Effect - Clinical Code	No Consequences Or Impact To Patient (2199)
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
Product complaint # (b)(4).The device history records were reviewed and the manufacturing criteria was met prior to the release of this lot.Attempts have been made to retrieve the device.To date the device has not been returned.If the device or further details are received at a later date a supplemental medwatch will be sent.
Event or Problem Description
It was reported a patient underwent a hartman¿s reversal procedure on an unknown date and suture was used.The needle broke into 2 pieces during use.Both pieces were retrieved a new suture was used.No patient consequences.

• Brand Name: ETHLN BLK 96IN 0 S/A CT LP
• Common Device Name: SUTURE, NONABSORBABLE, SYNTHETIC
• Manufacturer (Section D): ETHICON INC.; p.o. box 151, route 22 west; somerville NJ 08876 0151
• MDR Report Key: 8335673
• Report Number: 2210968-2019-78843
• Device Sequence Number: 11028821
• Product Code: GAR
• UDI-Device Identifier: 10705031044913
• UDI-Public: 10705031044913
• Combination Product (Y/N): N
• Initial Reporter Country: CA
• PMA/510(K) Number: K946173
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: company representative,foreig
• Initial Reporter Occupation: Other
• Type of Report: Initial
• Report Date (Section B): 01/16/2019

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this an Adverse Event Report?: No
• Is this a Product Problem Report?: Yes
• Operator of Device: Health Professional
• Device Expiration Date: 07/31/2019
• Device Catalogue Number: L886T
• Device Lot Number: HMH004
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Initial
• Initial Date Received by Manufacturer: 01/16/2019
• Initial Report FDA Received Date: 02/13/2019
• Patient Sequence Number: 1